IP Journal of Otorhinolaryngology and Allied Science

Print ISSN: 2582-4147

Online ISSN: 2582-421X

CODEN : IJOABK

IP Journal of Otorhinolaryngology and Allied Science (JOAS) open access, peer-reviewed quarterly journal publishing since 2018 and is published under the Khyati Education and Research Foundation (KERF), is registered as a non-profit society (under the society registration act, 1860), Government of India with the vision of various accredited vocational courses in healthcare, education, paramedical, yoga, publication, teaching and research activity, with the aim of faster and better dissemination of knowledge, we will be publishing the article more...

  • Article highlights
  • Article tables
  • Article images

Article statistics

Viewed: 245

PDF Downloaded: 117


Get Permission Sah, Shilpakar, Sah, Yadav, Rai, Sharma, and Sarraf: Functional and aesthetic outcome of different technique for lip reconstruction after ablative surgery of lip carcinoma at a comprehensive cancer care center in Nepal


Introduction

Lip cancer accounts for 23.6 to 30% of malignant tumors of the oral cavity. 1 Squamous cell carcinoma (SCC) is the most common malignancy related to the lips (95%) and the lower lip is more commonly involved in comparison to upper lip (90% ). 2 SCC of the lip is thought to be related to sun exposure.1 However, the etiology of lip cancer is multifactorial, including exposure to sunlight, tobacco, genetic predisposition, immunosuppression and immunodeficiency. 3 The accepted method of lip cancer treatment is full-thickness surgical resection of the skin, muscle and underlying mucosa to allow a safe surgical margin. In presence of poor prognostic indicators like multiple levels of positive lymph nodes, extra capsular extension of the cancer in lymph nodes, deep invasion of the primary tumor, neural and vascular invasion and tumor margins less than 5mm, tumors of the lips should be treated with surgery and postoperative radiation. 4 Defect in the lip is treated with a variety of reconstructive techniques, depending on site, size and type of the defect. The subsequent reconstruction should satisfy two fundamental requirements: 1) to conserve labial function & maintain continence & 2) to achieve acceptable aesthetic appearance. 5 Therefore, reconstruction of lip is a challenge to restoration of both function & aesthesis after tumor resection. This study was aimed to evaluate the functional and aesthetic outcome of different techniques used in the lip reconstruction after Lip cancer ablative surgery.

Material and Methods

This retrospective study was conducted in Department of Head and Neck Oncology & Reconstructive Surgery of Purbanchal Cancer Hospital a sister wing of B & C medical college from January 2021 to December 2023 after getting clearance from the institutional ethical committee. The patients with lip carcinoma treated with surgical resection leaving the defect and reconstructed with different techniques (primary, local, distant and microvascular free flap) were enrolled. Anatomic location of the lip defects (skin, vermillion, or both), thickness of the lip defect (partial thickness or full thickness), and width of the lip defect relative to the overall width of the lip were used to classify the lip defect into three categories: 1) defects less than one-third of the total lip length, 2) defects between one-third and two-thirds of total lip length, and 3) total lip defects. 6, 7, 8 The different technique of lip reconstruction was done according to the standard operative techniques.

All patients were evaluated preoperatively by clinical examination and radiological imaging for cancer staging for treatment (tumor resection and appropriate neck dissection followed by radiotherapy and/or chemotherapy those patients having oncological indication after histopathological report). Preoperative and postoperative and subsequent follow up photographic documentation were done. The functional and aesthetic results were evaluated at the end of 12 weeks. Oral competence, lip mobility, and sensations were used for functional assessment. The patients were asked to evaluate the subjective overall function of the reconstructed oral commissure in terms of speech integrity and oral competence) with four grades (4 -excellent; 3- good; 2- satisfactory; 1- poor).

For aesthetic assessment, followings methods were used: i) lip appearance at rest (symmetrical or asymmetrical), ii) size of the lip in a horizontal and vertical direction, iii) status of oral stoma (severe microstomia, moderate microstomia, or normal stoma), iv) commissure (acute or obtuse), v) scar aesthetics in nasolabial and mentolabial crease and vi) size of new vermilion to available old residual vermilion. Two surgeon’s assessment and comments as well as patients’ comments were also taken into consideration for aesthetics outcomes with four grades (4-excellent; 3- good; 2- satisfactory; 1- poor). Descriptive analysis of the data was performed using the statistical package software SPSS 16.0 (SPSS Inc., Chicago, IL, USA).

Results

There were 17 patients i.e. 12 male and 5 females. The patient age range between 34 and 91 years (mean age was 52.23 year). Lower lip had tissue defects in 16 cases and involved commissure in eight cases. Out of the 17 patients, five patients had a defect size up to 1/3, six patients had a defect size of 1/3 to 2/3 and six patients had a defect size >2/3.

Out of 17 patients four patients had primary closure by W plasty and V platy technique (Figure 1), one patient lip & commissure by Zisser Flap (Figure 2), three patients lip advancement and Karapandzic flap (Figure 3, Figure 4, Figure 5), one patient Bilateral Webster Bernard Flap (Figure 6 ), two patients nasolabial flap (Figure 7), one patient bilobed pectoralis major myocutaneous flap (Figure 8), two patients free radial artery fore- arm flap with palmaris tendon (Figure 9, Figure 10), two patients with free anterolateral thigh flap in which facia lata was used to make a sling in one case (Figure 11) and one patient lip & mandibular reconstruction with free fibula osteocutaneous flap (Figure 12). The patients’ characteristics, reconstructive techniques, tissue defect location and size, functional and aesthetic outcome, and complications are shown in Table 1.

Table 1

The patients’ characteristics, reconstructive techniques, tissue defect location and size, functional and aesthetic outcome, and complications (n=17)

SN

Age/Sex

Defect size

location

Relation to commissure

Reconstructive techniques

Complication

Functional Outcome

Aesthetic outcome

Microstoma

Oral competence

Speech problem

1.

91/M

1/3rd

Central, lower lip

Not involved

W- Plasty

Nil

NO

competence

No

Excellent

2.

34/F

< 1/3rd

Right. Lower lip

Involved

Right Zisser Flap

Nil

NO

competence

No

Excellent

3

42/M

1/3rd – 2/3rd

Right central lower lip

Not involved

Bilateral Karapandzic Flap

Hypertrophic scar

Moderate

competence

No

Good

4

40/F

1/3rd – 2/3rd

Central upper lip

Not involved

Bilateral reverse Karapandzic Flap

Hypertrophic scar

Moderate

competence

No

Good

5

43/M

1/3rd – 2/3rd

Left lower lip

Involved

Right Karapandzic flap + and Left Estlander flap

Nil

Moderate

competence

Minimal

Satisfactory

6

60/M

>2/3rd

Left central lower lip

Involved

Bilateral Webster Bernard Flap

Minor wound dehiscence healed spontaneously

NO

competence

No

Excellent

7

57/M

1/3rd

Left Upper lip

Involved

Left Bilobed Pectoralis Major Myocutaneous Flap

Nil

Moderate

Slight incompetence

Minimal

Satisfactory

>1/3rd

Lower lip

8

45/M

>2/3rd

Right lower lip

Involved

Left Radial forearm free Flap

Nil

NO

Slight incompetence

Minimal

Good

9.

51/M

>2/3rd (100%)

Lower li[p

Involved

Free Fibula Osteocutaneous Flap

Nil

No

competence

Minimal

Satisfactory

10

62/M

>2/3rd

Lower lip

Involved

Left Radial forearm free Flap with Palmaris tendon sling

Nil

No

competence

No

Good

11.

47/M

>2/3rd

Lower lip

Involved

Anterolateral Thigh (ALT) Flap

Seroma

Moderate

Slight incompetence

Minimal

Satisfactory

12.

53/F

1/3rd

Lower lip

Not involved

W plasty

Nil

No

competence

No

Excellent

13.

56/F

1/3rd – 2/3rd

Lower lip

involved

Nasolabial Flap

Nil

No

competence

No

Excellent

14.

61/M

1/3rd – 2/3rd

Lower lip

involved

Nasolabial Flap

Nil

No

competence

No

Good

15.

46/M

1/3rd – 2/3rd

Lower lip

Not involved

Bilateral Karapandzic Flap

Nil

Minor

competence

No

Good

16.

51/F

< 1/3rd

Lower Lip

Not involved

V plasty

Nil

No

competence

No

Excellent

17

49/M

< 1/3rd

Lower Lip

Not involved

V plasty

Nil

No

competence

No

Excellent

Out of 17 patients the functional outcomes were: 14 patients had good Oral competence and three patients had slight incompetence during taking foods, six patients had developed microstomia those were reconstructed with local flap and five patients experienced disturbance in some degree of speech integrity. Aesthetic outcome was excellent in seven cases, good in six cases and satisfactory in four cases. In one case, we had minor wound dehiscence that healed spontaneously, one had seroma and resolved with serial needle aspiration and two patients had developed hypertrophic scar.

Figure 1

Lip reconstruction with W-plasty

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image1.png
Figure 2

Lip reconstruction with Zisser Flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image2.png
Figure 3

Lip reconstruction with Karapandzic Flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image3.png
Figure 4

Lip reconstruction with karapandzic flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image4.png
Figure 5

Lip reconstruction with Rt. Karapandzic flap + Lt. Estlander flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image5.png
Figure 6

Lip reconstruction with webster bernard flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image6.png
Figure 7

Lip Reconstruction with nasolabial flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image7.png
Figure 8

Lip with commissural reconstruction with Bipedal Left PMMC Flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image8.png
Figure 9

Near total lip reconstruction with left radial forearm free flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image9.png
Figure 10

Total lip reconstruction with radial forearm free flap with palmaris tendon sling

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image10.png
Figure 11

Lip with commissural reconstruction with anterolateral thigh alap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image11.png
Figure 12

Lip with commissural reconstruction with fibula osteocutaneous free flap

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/8afc4ebd-deba-46a3-b874-944669065949image12.png

Discussion

Lips play an important role in speech, swallowing and facial expression and facial cosmetics9. The reconstruction of lip secondary to ablative surgery requires careful planning so as to restore the normal function by reestablishing oral competence, maintaining adequate mouth opening, maintain the mobility of lips, preserve sensation and aesthetics. 9, 10

   Following lip resection, reconstruction by applying the principle of like for like should be followed whenever possible. However, this may not be easily achievable with large defects and when there is scarcity of tissues of similar qualities. Nevertheless, the method of lip reconstruction should aim at maintaining sphincter function which prevents sialorrhea, acquiring an adequate mouth opening, achieving an aesthetically pleasing outcome and skin coverage. 11

Full-thickness defects repair consists of reconstitution of skin, muscle, and mucosa. In case of defects involving less than one-third of the lip, primary closure is usually possible without following “tight lip” or significant microstomia.8 The V excision, followed by primary synthesis, should be the first option to repair defects affecting up to 30% of the lower lip, 5, 9, 12, 13, 14, 15, 16, 17, 18 In this study 4 patients of defects affecting up to 1/3 of the lip, reconstructed with primary sutures, V excisions were performed in 2 and 2 patients, in which a W excision was performed (Figure 1).

When more than 1/3 of the lip is lost, the local flaps are the best options for reconstruction.[5,9,12-91]5, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 The most commonly used techniques, which offer good results, are the use of rotation and advancement flaps in the oral commissure, such as the Karapandzic flaps, 20, as well as lip transfer flaps such as the Abbé 21 and Estlander 22 flaps. In present study, 3 patients lip reconstructed with Karapandzic flaps in which Estlander flap used in one (Figure 3, Figure 4, Figure 5 ). In those patients with good skin laxity Karapandzic flap is a viable option for medium to large sized full thickness defects as it provides single stage reconstruction with good oral competence and normal sensation; however, lip asymmetry and microstomia are notable. It is a single stage flap that can be used for the lower and upper lip and has good sensation and oral competence; however, it is associated with microstomia. 10, 23, 24 In this study also microstomia seen in all three cases of Karapandzic flap reconstruction patients. Undoubtedly, the oral commissure is the most difficult region to reconstruct from a functional and aesthetic point of view. 25 Reconstruction of a vertically oriented commissural defect by means of combined cheek-skin advancement and an intraoral mucosal flap was first described in 1975 by Zisser. 26 The Bernard–von Burow–Webster procedure is a headway fold with the extraction of cutaneous triangles. Webster strategy is generally utilized for lower lip absconds more than 80%. 27, 28 We were able to get quite acceptable functional and aesthetic results in patient of our study (Figure 6).

Nasolabial flap can be used for large full thickness lip defects in case of intolerable microstomia; it is also useful in commissural defects with buccal mucosal lesion that needs cover after excision. Vermilion mismatch is obvious and the flap is generally made thin to match the remaining lip tissue bulk. Central defect and single lip lateral defect usually don’t have problem of incompetence. 29 We got good functional and aesthetic results in patient of our study (Figure 7). It has been reported that free flap successfully was used in total lip reconstruction with excellent results. 30, 31, 32 As donor site tissue is different from oral tissue, the free flap is largely limited about oral function and aesthetic outcomes. A single-stage reconstruction of total lip defects including affected areas of cheek and/ or chin is achieved with micro-vascular reconstruction. For reconstruction of the entire lower lip, fasciocutaneous flaps (e.g., radial forearm and anterolateral thigh flaps) have proven to be reliable. 33, 34, 35, 36 In case if intolerable microstomia, free radial artery forearm flap with or without palmaris longus sling are used for total lip defect, lip defect along with buccal mucosal defect and less local tissue for reconstruction. Lip defect along with involvement of commissure leads to oral incompetence. However, incorporation of palmaris longus sling in central and whole lip defect had good oral competence in our study. Similar findings were also reported by Özdemir et al. in which all patients had good oral competence, sensation and acceptable aesthetic results. 37

The use of free revascularized osteo-cutaneous flaps (e.g., fibula or iliac crest flaps) permits reconstruction of large composite defects of the lip and mandible. 38 In present study, five patients lip reconstruction done with free flap i.e. two patients free radial artery fore- arm flap with palmaris tendon (Figure 9, Figure 10), two patients with Free Anterolateral thigh Flap in which facia Lata was used to make a sling in one case (Figure 11) and one patient lip & mandibular reconstruction with Free Fibula Osteocutaneous flap (Figure 12) with good functional and aesthetic results.

Conclusion

The selection of flap technique for lip reconstruction after carcinoma resection depends on multiple factors, including defect size, patient-specific considerations, and long-term goals. Local flaps often provide good aesthetic outcomes and adequate function for smaller defects, while regional and free flaps are preferable for extensive reconstructions to ensure functional integrity. Achieving a balance between functional efficacy and aesthetic acceptability is paramount, with individualized treatment planning being essential for optimal patient satisfaction.

Source of Funding

None.

Conflict of Interest

None.

References

1 

W Rena Y Lia C Liua C Qianga L Zhang L Gaoa Surgical management of squamous cell carcinoma of the lower lip: an experience of 109 cases. Med Oral Patol Oral Cir Bucal2014194398402

2 

EF Williams C Hove Lip ReconstructionSemin Plast Surg200222463445Thieme

3 

JG Devisscher IV Der Waal Etiology of cancer of the lip. A reviewInt J Oral Maxillofac Surg199827199203

4 

L David S Mathes Tumors of the Lips, Oral Cavity and OropharynxElsevier200615980

5 

PC Neligan Strategies in lip reconstructionClin Plast Surg200936347785

6 

L Harris K Higgins D Enepekides Local flap reconstruction of acquired lip defectsCurr Opin Otolaryngol Head Neck Surg201220425461

7 

C Burusapat A Pitiseree Advanced squamous cell carcinoma involving both upper and lower lips and oral commissure with simultaneous reconstruction by local flap: a case reportJ Med Case Rep2012623

8 

JE Lubek RA Ord Lip ReconstructionOral Maxillofac Surg Clin North Am20132520317

9 

D Baumann G Robb Lip reconstructionLip Reconst Se- min Plast Surg20082226980

10 

A Ebrahimi GR Maghsoudnia AA Arshadi Prospective comparative study of lower lip defects reconstruction with different local flapsJ Craniofac Surg2011226225564

11 

EA Luce Reconstruction of the lower lipClin Plast Surg19952210930

12 

BA Anvar BC Evans GR Evans Lip ReconstructionPlast Reconstr Surg200712045764

13 

H Langstein G Robb Lip and perioral reconstructionClin Plast Surg200532343176

14 

EJ Siqueira GS Alvarez FL Laitano Pde Martins MP Oliveira Estratégias em reconstrução do lábio inferiorRev Bras Cir Plást201227453677

15 

GJ Renner Local flaps in facial reconstructionSt. Louis: Mosby2008116

16 

JP Pepper SR Baker Local flaps: cheek and lips reconstruc- tionJAMA Facial Plast Surg201315537482

17 

C Dupin S Metzinger R Rizzuto Lip reconstruction after ablation for skin malignanciesClin Plast Surg20043116985

18 

E Dediol I Luksić M Virag Treatment of squamous cell carcinoma of the lipColl Antropol2008322199202

19 

J C Sbalchiero R Anlicoara M C Cammarota Pra Leal Reconstrução labial: abordagem funcional e estética após ressecção tumoralRev Soc Bras Cir Plást20052014045

20 

M Karapandzic Reconstruction of lip defects by local arte- rial flapBr J Plast Surg197427193100

21 

Abbe R A new plastic operation for the relief of deformity due to double harelipPlast Reconstr Surg1968425481484

22 

J Estlander Eine Methode, aus der einen Lippe Substanzverluste der anderen zu ersetzenArch Klin Chir187214622622

23 

A S Dadhich S Shah H Saluja P Tandon V More Karapandzic Flap for Esthetic and Functional Reconstruction of Large Defect of Lower Lip. Ann Maxillofac Surg20177300303DOI:10.4103/ams.ams_127_17

24 

G L Coppit D T Lin B B Burkey Current concepts in lip reconstructionCurr Opin Otolaryngol Head Neck Surg2004124

25 

J J Closmann M A Pogrel B L Schmidt Reconstruction of perioral defects following resection for oral squamous cell carcinomaJ Oral Maxillofac Surg200664367374

26 

G Zisser A contribution to the primary reconstruction of the upper lip and labial commissure following tumour excisionJ Maxillofac Surg19753211217

27 

V S Konstantinovic Refinement of the Fries and Webster modifications of the Bernard repair of the lower lipBr J Plast Surg199649462467

28 

G Wechselberger R Gurunluoglu T Bauer H Piza-Katzer T Schoeller Functional lower lip reconstruction with bilateral cheek advancement flaps: revisitation of Webster method with a minor modification in the techniqueAesthetic Plast Surg200226423431

29 

A I Shaikh A H Khan S Tated N Khubchandani Functional and aesthetic outcome of different methods of reconstruction of full thickness lip defectsGMS Interdiscip Plast Reconstr Surg DGPW202211

30 

M Daya V Nair Free radial forearm flap lip reconstruction: a clinical series and case reports of technical refinementsAnn Plast Surg200962361368

31 

S Furuta Y Sakaguchi M Iwasawa H Kurita T Minemura Reconstruction of the lips, oral commissure, and full-thickness cheek with a composite radial forearm palmaris longus free flapAnn Plast Surg199433544551

32 

M Keskin M Sutcu Z Tosun N Savaci Reconstruction of total lower lip defects using radial forearm free flap with subsequent tongue flapJ Craniofac Surg20102134951

33 

C M Carroll I Pathak J Irish P C Neligan P J Gullane Reconstruction of total lower lip and chin defects using the composite radial forearm--palmaris longus tendon free flapArch Facial Plast Surg200025359

34 

S F Jeng Y R Kuo F C Wei C Y Su C Y Chien Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: a clinical seriesPlast Reconstr Surg20041131923

35 

R C Sadove E A Luce P C Mcgrath Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flapPlast Reconstr Surg199188209223

36 

K Takada T Sugata K Yoshiga Y Miyamoto Total upper lip reconstruction using a free radial forearm flap incorporating the brachioradialis muscle: report of a caseJ Oral Maxillofac Surg19874595962

37 

R Ozdemir T Ortak U Kocer S Celebioglu O Sensoz Y O Tiftikcioglu Total lower lip reconstruction using sensate composite radial forearm flapJ Craniofac Surg200314393405

38 

W P Godefroy W M Klop L E Smeele P J Lohuis Free-flap reconstruction of large full-thickness lip and chin defectsAnn Otol Rhinol Laryngol2012121594603



jats-html.xsl


This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Article type

Original Article


Article page

35-44


Authors Details

Bajarang Prasad Sah


Article History

Received : 10-06-2024

Accepted : 17-07-2024


Article Metrics


View Article As

 


Downlaod Files